The indications for cholecystectomy are similar whether a laparoscopic or traditional open approach is performed (see Chapter 73). Today, most patients have a laparoscopic procedure to remove their gallbladder. The procedure described here is called open and is most commonly performed at a conversion to open when the initial laparoscopic approach encounters complex technical events (e.g., swollen, gangrenous gallbladder, confusing anatomy, abnormal cholangiogram) or major complications (e.g., ductal, vascular, or bowel injury) that are best treated with open exposure. Although open cholecystectomy is no longer the primary operation of choice, its mastery is essential for surgeons who perform laparoscopic cholecystectomy. A safe surgeon knows when it is appropriate to convert to an open operation and does not risk endangering the safety of patients in order to complete the procedure laparoscopically at all costs.
Open cholecystectomy can be performed in two ways: (1) retrograde approach (i.e., dissection of the triangle of Calot with identification and division of the cystic duct and artery followed by removal of the gallbladder) or (2) top-down approach (i.e., separation of the gallbladder from the liver with division of the cystic duct and artery as the final step).
Following a history and physical examination, the diagnosis of biliary disease is typically documented with ultrasound examination of the right upper quadrant. The remainder of the gastrointestinal tract may require additional studies. A chest x-ray and electrocardiogram may be performed as indicated. Routine laboratory blood tests are obtained and should include a liver function panel. Coagulation studies should be ordered if there is a concern for hepatic insufficiency or other causes of coagulopathy. The risks of cholecystectomy include bleeding, infection, visceral injuries, and bile duct injury. The management of patients with suspected common duct stones is based on risk stratification. Preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and stone extraction, if necessary, is indicated in patients with jaundice. Preoperative ERCP or magnetic resonance cholangiopancreatography should be considered for patients with dilated bile ducts on imaging and/or elevated liver function tests.
General anesthesia with endotracheal intubation is recommended. Deep anesthesia is avoided using a suitable muscle relaxant. In patients suffering from extensive liver damage, barbiturates as well as other anesthetic agents suspected of hepatotoxicity should be avoided. In elderly or debilitated patients, local infiltration anesthesia is satisfactory, although some type of analgesia is usually necessary as a supplement at certain stages of the procedure.
Proper positioning of patients on the operating table is essential to secure sufficient exposure (FIGURE 1). Arrangements should be made for an operative cholangiogram in the event that one is necessary. A fluoroscopic C-arm requires sufficient space to be centered under the patient to ensure coverage of the liver, duodenum, and head of the pancreas. The exposure can be enhanced by tilting the ...